Accelerating Anti-Retroviral Treatment as a catalytic action for Ending AIDS Pride Chigwedere, MD, PhD Senior Advisor to the African Union AWA CONSULTATIVE EXPERTS’ COMMITTEE MEETING OF COMMISSION OF THE AFRICAN UNION, NOUAKCHOTT, MAURITANIA MAY 2014

Calls for Ending AIDS Continental Calls Abuja + 12 Special Summit Common African Position for Post-2015 Agenda Global Calls MDGs 2011 Political Declaration Is it possible to End AIDS? Progress in last decade Interventions available

2011 UNGA Political Declaration targets 1 Halve sexual transmission 2 Halve infections among injecting drug users 3 Eliminate new HIV infections among children and halve AIDS-related maternal deaths 4 15 million people on HIV treatment 5 Halve tuberculosis deaths among people living with HIV 10 Eliminate parallel systems, for stronger integration 9 Eliminate travel related restrictions 8 Eliminate stigma and discrimination 7 Eliminate gender inequalities and sexual violence and increase capacities of women and girls 6 Close the global resource gap and achieve annual investment of US$ bn

A focus on treatment is strategic

Expected impact of HIV treatment in survival of a 20 years old person living with HIV in a high income setting (different periods) HIV treatment can normalize survival

Dramatic impact of HIV response on life expectancy Source: World Bank life expectancy data Slide courtesy D Birx, PEPFAR years

Efficacy of Major Biomedical Interventions for Sexual Transmission of HIV Efficacy (%) STD treatment (Mwanza) Male circumcision (Orange Farm, Rakai, Kisumu) HIV Vaccine* (Thai RV144) Microbicide* (CAPRISA tenofovir gel) PrEP (iPrEx - oral tenfovir/emtricitabine) ART in HIV+ partner (HPTN 052) 42% ( ) 57% ( ) 31% (1 - 51) 39% (6 - 60) 44% ( ) 96% ( ) * These interventions are not yet available. Source: Adapted from Padian et al, 2010; Abdool Karim, 2010; Grant et al, 2010; Cohen et al, 2011

Reducing viral loads to 100/mL reduces HIV transmission by 99% Transmissions per year Viral load / mL Source: Attia 2009 AIDS

A clear correlation between HIV treatment and incidence Source: Tanser et al. Science 2013;339: % (0.8%-1.4%) reduction in HIV incidence, for each 1.0% increase in treatment coverage. ART & HIV incidence: Hlabisa, South Africa p=0.325 p=0.003 p=0.013 p= Incidence rate ratio ART coverage 0%30%60%

Reducing the community viral load drives down acquired resistance to ARVs Incidence of acquired resistance (per year) Suppressed viral load (<50/mL) % 80% 70% 60% 2008 Source: Gill et al Clinical Infectious Diseases

Expanding access to ART is a smart investment: Case of South Africa Source: Expanding ART for Treatment and Prevention of HIV in South Africa: Estimated Cost and Cost-Effectiveness PLoS ONE 7(2):e30216

Significantly higher employment at CD4≥500 among adults Compared to CD4<200, CD4≥500 associated with – 5.8 more days/month – 2.2 more hours/day (40% more than ref. mean of 5.5) Linear regression model with age, age-squared, and sex included as controls ** p<0.05, * p<0.10 Reference group has CD4<200 Those with CD4≥500 worked nearly 1 week/month more than those with CD4<200, and as much as HIV-uninfected adults Source: Thirurmurthy, Health Affairs, 2012

Rapid Treatment Scale up … Prevents death Prevents active disease e.g. TB PMTCT of HIV: Option B+ Prevents new HIV infection Saves money and increases productivity Lays the foundation for the end of the AIDS epidemic

Scenarios of ARV eligibility: WHO vision Source: WHO 2014

Source: UNAIDS estimates 2013 Gap in antiretroviral coverage varies within Africa 7.6 million people on ART in Africa 21.2 million eligible under WHO 2013 Guidelines 25 million people living with HIV on continent

UNAIDS PCB calls for new targets Targets drive progress New scientific evidence Post 2015 Accountability A winnable challenge

Country and regional track: regional retargeting consultations

Continental AUC led processes July 2013 – Abuja + 12 Special Summit Nov 2013 – AUC/RECs Coordination Meeting Mar 2014 – Inter-Agency Meeting on AIDS May 2014 – AWA Experts Meeting June 2014 – AWA HoS Action Committee

Global track

Treatment cascade Sources: 1. UNAIDS 2012 estimates; 2. Demographic and Health Surveys, 2007–2011 ( 3. Kranzer, K., van Schaik, N., et al. (2011), PLoS ONE; 4. GARPR 2012; 5. Barth R E, van der Loeff MR, et al. (2010), Lancet Infect Disease. Notes: No systematic data are available for the proportion of people living with HIV who are linked to care, although this is a vital step to ensuring viral suppression in the community.

The treatment target 90 % testedon treatment virally suppressed

Challenges: Translating Science into Action What is the RIGHT thing to do? Question of Science Can I choose to do the RIGHT thing? Constrained or competing choices (Economic and Political Feasibility) Now that I have chosen the RIGHT thing, can I actually do the RIGHT thing RIGHT? Question of implementation Did everything turn out all RIGHT? Outcomes